Domperidone for delayed gastric emptying in lung transplant recipients with and without gastroesophageal reflux.

Evidence demonstrates a link between gastroesophageal reflux disease and chronic allograft dysfunction in lung transplant recipients. Delayed gastric emptying plays an important role in the occurrence of gastroesophageal reflux disease, with limited therapeutic options available for treatment. This retrospective observational study reports the use of domperidone in the management of delayed gastric emptying in lung transplant recipients. All patients who underwent lung transplant at our institution from 2007 to 2011 were reviewed and patients who were treated with domperidone were identified. Clinical symptoms and results of gastric emptying studies before and after initiation of domperidone were documented. QTc intervals were compared from before to after domperidone treatment at 3 months and at 1 year. Weight and dose-normalized calcineurin inhibitor troughs were evaluated before and 2 weeks after domperidone treatment was started. Of 82 patients, 24% (n = 20) had documented delayed gastric emptying and 35% (n = 29) had documented gastroesophageal reflux disease. Twelve of the 20 patients with delayed gastric emptying started treatment with domperidone. All patients responded symptomatically and 6 patients with gastric emptying studies before and after domperidone had documented improvement. No adverse effects were observed in any patients treated with domperidone. Results indicate that domperidone can be used safely and may improve symptoms related to delayed gastric emptying in lung transplant recipients.

Congestive heart failure and chronic obstructive pulmonary disease predict poor surgical outcomes in older adults undergoing elective diverticulitis surgery.

BACKGROUND: Diverticulitis is a common medical condition that disproportionately affects older adults. The ideal management of recurrent diverticulitis, including the role of prophylactic colectomy, remains uncertain. OBJECTIVE: This study aimed to investigate the outcomes among older patients undergoing elective surgery for diverticulitis and examine subgroups of patients with comorbid congestive heart failure and chronic obstructive pulmonary disease to determine whether outcomes in these patients are worse than in other groups. DESIGN: This article reports a retrospective cohort study of patients undergoing elective surgery for diverticulitis. SETTING: Data were derived from the 100% Medicare Provider Analysis and Review inpatient files from 2004 to 2007. PATIENTS: Included were 22,752 patients, age 65 years and older, with a primary diagnosis of diverticulitis that underwent elective left-colon resection, colostomy, or ileostomy. MAIN OUTCOME MEASURE: The primary outcome measure was in-hospital mortality. The secondary outcome measures were intestinal diversion rates (colostomy and ileostomy) and postoperative complications. RESULTS: Overall mortality, intestinal diversion (colostomy and ileostomy), and postoperative complication rate were 1.2%, 11.3%, and 22.1%. Patients with congestive heart failure had increased odds of in-hospital mortality (OR 3.5, 95% CI 2.59-4.63), colostomy (OR 1.9, 95% CI 1.69-2.27), and all postoperative complications, including hemorrhagic (OR 1.5, 95% CI 1.01-2.11), wound (OR 1.9, 95% CI 1.50-2.39), pulmonary (OR 4.2, 95% CI 3.59-4.85), cardiac (OR 4.6, 95% CI 3.68-5.74), postoperative shock/sepsis (OR 3.2, 95% CI 2.53-4.35), renal (OR 4.1, 95% CI 3.22-5.12), and thromboembolic (OR 1.6, 95% CI 1.00-2.43) complications. Patients with chronic obstructive pulmonary disease had significantly increased odds of wound (OR 1.4, 95% CI 1.19-1.67) and pulmonary (OR 2.2, 95% CI 1.94-2.50) complications. Advancing age, congestive heart failure, and chronic obstructive pulmonary disease were significantly associated with increased morbidity and mortality. LIMITATIONS: Medicare data are limited by the potential for lack of generalizability to patients <65 years and the potential for coding errors. CONCLUSIONS: Elective diverticular surgery in older patients carries substantial morbidity, especially in those patients with comorbid congestive heart failure and chronic obstructive pulmonary disease. The rate of perioperative complications that we document in this patient population may attenuate some of the expected benefit of surgery.

Improving burnout and well-being among medicine residents: Impact of a grassroots intervention compared to a formal program curriculum.

BACKGROUND: With growing resident burnout, Accreditation Council for Graduate Medical Education issued new requirements for program interventions to optimize resident well-being. Little evidence exists on how to best teach resiliency to residents. This study assesses the impact of both a grassroots intervention and formal resiliency curriculum on resident burnout and well-being. MATERIALS AND METHODS: From November 2016 to August 2017, residents in a large Internal Medicine Residency Program participated in grassroots wellness interventions from the resident-led Gator Council in Gainesville, FL USA. From August 2017 to June 2018, residents participated in a formal program-driven resiliency curriculum. Wellness interventions included monthly morning reports, bimonthly workshops, and biannual noon conferences. Pre- and postintervention Maslach Burnout Inventory (MBI) and Physician Well-Being Index (PWBI) assessed the effect of both interventions on resident burnout and well-being. Statistical analyses used Student's t-test, Fisher's exact tests, and linear regression model. RESULTS: One hundred and twenty-two residents participated in grassroots interventions. One hundred and seventeen (87 residents, 35 students) participated in formal curriculum. Mean MBI scores for all three sections did not differ between pre -and postgrassroots intervention (emotional exhaustion [EE] P = 0.46; depersonalization [DP] P = 0.43; personal accomplishment [PA] P = 0.73]) or between pre- and postcurriculum (EE P = 0.20; DP P = 0.40; PA P = 0.51). Students scored higher burnout levels compared to residents in EE (P = 0.001) and PA (P = 0.02). Pre- versus postcurriculum PWBI scores did not differ among residents (P = 0.20), while PWBI scores improved among students (P = 0.01). CONCLUSIONS: This study found no improvement in resident burnout or well-being from a bottom-up and top-down approach. Our results imply the need for an early wellness curriculum to improve student well-being given their higher level of burnout. System-wide efforts are vital to combat physician burnout.

Differential association of race with treatment and outcomes in Medicare patients undergoing diverticulitis surgery.

BACKGROUND: Observed racial disparities in diverticulitis surgery have been attributed to differences in health insurance status and medical comorbidity. OBJECTIVE: To examine disparities in procedure type (elective vs urgent/emergency) and mortality in patients with surgically treated diverticulitis insured by Medicare, accounting for comorbidities. DESIGN: Retrospective analysis of Medicare Provider Analysis and Review inpatient data. PATIENTS: All blacks and whites 65 years and older undergoing surgical treatment for primary diverticulitis with complete admission and outcome data were eligible. MAIN OUTCOME MEASURES: In-hospital mortality was examined across procedure categories (elective vs urgent/emergency). Multivariable regression controlled for age, sex, and medical comorbidity (Charlson Comorbidity Index). RESULTS: A total of 49 937 whites and 2283 blacks met the study criteria. Blacks were slightly younger (74.7 vs 75.5 years, P < .001) and more likely to be female (75.2% vs 69.8%, P < .001). Blacks carried greater comorbidity than did whites (mean Charlson Comorbidity Index score: 0.98 vs 0.87, P < .001); 67.8% of blacks vs 54.7% of whites (P < .001) were urgent/emergency. After adjustment, blacks demonstrated 26% greater risk of urgent/emergency admission (relative risk, 1.26; 95% CI, 1.22-1.30). Black race was also associated with a 28% greater risk of mortality (relative risk, 1.28; 95% CI, 1.10-1.51). CONCLUSIONS: Blacks underwent urgent/emergency surgery more often than did whites. Blacks demonstrated significantly increased mortality risk after controlling for age, sex, and comorbidities. These findings suggest that observed racial disparities encompass more than just insurance status and medical comorbidity. Mechanisms leading to worse outcomes for blacks must be elucidated.

Interest in marijuana treatment programs among teenage smokers and nonsmokers.

Little is known about adolescents' interest in marijuana treatment programs. This question was evaluated by telephone interview in a convenience sample of 575 adolescents responding to advertisements for tobacco research studies. Eighty-one percent of respondents endorsed the need for marijuana treatment programs for adolescents. These adolescents were younger and less likely to smoke tobacco, smoke marijuana, or use alcohol than those not endorsing such a need. Among the 192 marijuana smokers, the 58.8% who endorsed the need for marijuana treatment programs took their first puff of marijuana at a younger age than those who did not endorse the need. Those who were willing to participate in a marijuana treatment program were more likely African American and took their first marijuana puff at a younger age than those not interested in treatment. These findings suggest that most adolescent marijuana smokers endorse the need for and are willing to attend marijuana treatment programs.